872 F.

2d 56

25 Soc.Sec.Rep.Ser. 278, Unempl.Ins.Rep. CCH 14613A

Mary W. HINES, Plaintiff-Appellant,
v.
Otis R. BOWEN, Secretary of Health and Human Services,
Defendant-Appellee.
No. 88-2868.

United States Court of Appeals,

Fourth Circuit.
Argued Jan. 9, 1989.
Decided March 10, 1989.

Sara Elliott Krome (Pamlico Sound Legal Services on brief) for plaintiffappellant.
Stephen Aubrey West, Asst. U.S. Atty. (Margaret Person Currin, U.S.
Atty., on brief) for defendant-appellee.
Before CHAPMAN, Circuit Judge, BUTZNER, Senior Circuit Judge, and
MOTZ, District Judge from the District of Maryland, Sitting by
Designation.
CORRECTED OPINION
PER CURIAM:

Mary W. Hines appeals from the order of the district court denying her
disability insurance benefits and supplemental security income under 42 U.S.C.
Sec. 401 et seq. and 42 U.S.C. Sec. 1381. The district court found that there
was substantial evidence to support the conclusion of an Administrative Law
Judge (ALJ) that Hines does not have an impairment or combination of
impairments listed in or medically equivalent to any of those listed at 20 C.F.R.
Pt. 404, Subpart P, App. 1 (1988), and that Hines' medical problems do not
prevent her from continuing past relevant work as it is performed in the
national economy. Because we believe the Secretary failed to consider and to
explain the combined effect of Hines' impairments on her ability to work, we

vacate the decision of the district court and return it to the Secretary for further
consideration.
I.
2

Mary Williams Hines is a 63 year old former nursing assistant. She has a ninth
grade education. Before her 1984 retirement Hines was employed for thirty
years at a hospital in her hometown of Williamston, North Carolina. Hines
claims that since August, 1984, a combination of ailments has prevented her
from continuing this work.

Hines first filed for benefits in May, 1985. Although an ALJ denied her
application in January, 1986, the Social Security Administration's Appeals
Council subsequently vacated the ALJ decision in March, 1986. The Appeals
Council considered that Hyatt v. Heckler, 579 F.Supp. 985 (W.D.N.C.1984),
aff'd, 757 F.2d 1455 (4th Cir.1985), required a less restrictive review of
potential disabilities caused by diabetes, hypertension, or pain. However, after a
second hearing, on December 2, 1986, another ALJ denied Hines' claim.
Following an unsuccessful attempt to have this second decision overturned by
the Social Security Administration's Appeals Council, Hines brought this action
in the Eastern District of North Carolina. The district court granted summary
judgment in favor of the Secretary on May 16, 1988.

The relevant medical evidence consists of Hines' personal testimony and the
reports of examining and Social Security Administration physicians. In her
written applications and in her appearance before the ALJ Hines stated that
when she stopped working she suffered from pain in her arms, feet, and chest.
She described debilitating arthritis, particularly in her wrists. Since 1981 she
has been hospitalized and treated for hypertension, chest pain, and a kidney
infection. As of the July, 1986 hearing, Hines weighed 221 pounds; she is 5' 1
1/2" tall. Despite regular treatment, including medication, for various illness,
Hines reported that she continues to suffer from chest pain, high blood pressure,
and severe pain in her wrists, knees, and feet. Her joint pain is a result of
arthritis and gout. Hines also claims that her daily medications produce
dizziness and drowsiness.

Hines' problems have been further identified by physicians. Non-examining,

Social Security Doctors Issac Wright and J.H. Dykes recognized that Hines has
a history of hypertensive cardiovascular disease, osteoarthritic cardiovascular
disease with chest pain, exogenous obesity, diabetes, and gout. One of Hines'
personal physicians, Beverly Lewis, who treated Hines during the period of this
disability application, reported that Hines had shortness of breath with minimal

physical exertion, had intermittent burning pain in her feet, hypertension,

peripheral vascular disease, chest pain, hyperglycemia, diabetes, and with a
weight of just over 226 pounds, exogenous obesity. Two other examining
physicians, John Blount and Omatta Sirisena, reached similar conclusions.
II.
6

The general procedure of a Social Security disability inquiry is well

established. Five questions are to be asked sequentially during the course of a
disability determination. 20 C.F.R. Secs. 404.1520, 1520a (1988). An ALJ
must consider (1) whether the claimant is engaged in substantial gainful
activity, (2) whether the claimant has a severe impairment, (3) whether the
claimant has an impairment which equals a condition contained within the
Social Security Administration's official listing of impairments (at 20 C.F.R. Pt.
404, Subpart P, App. 1), (4) whether the claimant has an impairment which
prevents past relevant work, and (5) whether the claimant's impairment
prevents her from any substantial gainful employment. An affirmative answer
to question 1 or negative answers to questions 2 or 4 result in a determination of
no disability. Affirmative answers to questions 3 or 5 establish disability. 20
C.F.R. Sec. 404.1520. An ALJ's factual determinations must be upheld if
supported by substantial evidence, Smith v. Schweiker, 795 F.2d 343, 345 (4th
Cir.1986), but this court is not so restrained in determining whether correct
legal standards were applied. Coffman v. Bowen, 829 F.2d 514, 517 (4th
Cir.1987).

Hines' appeal does not involve questions one or two of the sequential
evaluation, as the ALJ conceded that Hines was not presently engaged in
substantial gainful activity. He further admitted that she was "severely
impaired." Regarding question three, however, the ALJ determined that Hines'
condition did not meet or exceed the requirements of any impairment listed at
20 C.F.R. Pt. 404, Subpart P, App. 1. Proceeding to question four, the ALJ
decided that Hines' limited impairments did not prevent her from continuing her
past relevant work as a nurse's aid. Because the question of disability under the
five-part scheme was resolved by a negative answer to question four, it was not
necessary for the ALJ to continue to an examination of question five, involving
whether Hines' impairment prevented her from performing any other kind of
work.

Despite the fact that the ALJ ostensibly denied benefits based on Hines'
purported ability to work as a nurse's aid, his decision was ultimately dependent
on an evaluation of Hines' impairments. The best evidence of the ALJ's
reasoning is his decision, which discusses various aspects of Hines' medical

condition. The ALJ mentioned Hines' history of hypertension, diabetes, chest

pain, obesity, joint pain and peripheral vascular disease. Yet the ALJ stressed
that Hines' worst problems were either controlled by medication, or were not
adequately proven by objective evidence. He concluded that the impairments,
alone or in combination, did not meet or equal any of the Subpart P listings.
9

Hines concedes that not one of her conditions by itself equals the requirements
of a Subpart P listing. Her position is that, when considered in combination, the
sum of her impairments are severe enough to allow her to adequately
approximate the requirements of listing 10.10, which provides for a finding of
disability under certain circumstances of gross obesity.1 Without deciding the
ultimate question of whether Hines is or is not entitled to receive benefits on
this basis we believe that the ALJ did not adequately discuss Hines' borderline
obesity, and more important, discuss how Hines' various impairments might
combine with one another to create a medical equivalence with 10.10 or another
listed impairment.

10

A failure to establish disability under the listings by reference to a single,

separate impairment, does not always prevent a disability award. Congress
explicitly requires that "the combined effect of all the individual's impairments"
be considered, "without regard to whether any such impairment if considered
separately" would be sufficiently severe. 42 U.S.C.A. Sec. 423(d)(2)(c) (1982
and Supp.1988). Further, this court has held that in determining whether an
individual's impairments are of sufficient severity to prohibit basic work related
activities, an ALJ must consider the combined effect of a claimant's
impairments. Reichenbach v. Heckler, 808 F.2d 309, 312 (4th Cir.1985);
DeLoatche v. Heckler, 715 F.2d 148, 149 (4th Cir.1983); Oppenheim v. Finch,
495 F.2d 396, 398 (4th Cir.1974); Hicks v. Gardner, 393 F.2d 299, 302 (4th
Cir.1968). It is also clear that the ALJ must adequately explain his or her
evaluation of the combined effect of impairments. Reichenbach, 808 F.2d at
312. This rule merely elaborates upon the general requirement that a ALJ is
required to explicitly indicate the weight given to relevant evidence. Murphy v.
Bowen, 810 F.2d 433, 437 (4th Cir.1987); Gordon v. Schweiker, 725 F.2d 231,
235-36 (4th Cir.1984).

11

The ALJ here has not satisfied any of these basic requirements. Despite the fact
that Hines is only a few pounds below the threshold weight specified in listing
10.10, the ALJ failed to sufficiently explain why obesity could not be
considered disabling. The ALJ also wrongly concluded that Hines' angina was
only "possible." This condition was conclusively established by the record.
Moreover, Hines' high blood pressure, joint pain, and the negative impact of her
medication were insufficiently addressed, for unexplained reasons. As a result

of these errors and omissions, the ALJ did not demonstrate that he adequately
considered the combined effect of Hines' impairments. It is necessary to the
review process that this court be given a full explanation. The ALJ must make
a particularized finding on the effect of the combination of impairments.
12

The judgment of the district court is reversed and the case shall be remanded
with instructions to return it to the Secretary for further proceedings in
accordance with this opinion. We deny appellant's motion to submit additional
evidence on appeal, but this denial is without prejudice to apellant's right to
submit such evidence to the Secretary on remand.

13

REVERSED AND REMANDED WITH INSTRUCTIONS.

10.10 Obesity. Weight equal to or greater than the values specified in Table I
for males. Table II for females (100 percent above desired level) and one of the
following:
A. History of pain and limitation of motion in any weight bearing joint or spine
(on physical examination) associated with X-ray evidence of arthritis in a
weight bearing joint or spine; or
B. Hypertension with diastolic blood pressure persistently in excess of 100 mm.
Hg measured with appropriate size cuff; or
C. History of congestive heart failure manifested by past evidence of vascular
congestion such as hepatomegaly, peripheral or pulmonary edema; or
D. Chronic venous insufficiency with superficial varicosities in a lower
extremity with pain on weight bearing and persistent edema; or
E. Respiratory disease with total forced vital capacity equal to or less than 2.0L.
or a level of hypoxemia at rest equal to or less than the value specified in Table
III-A or III-B or III-C.

TABLE II--WOMEN (PART)

-------------------------------------------------Height without shoes (inches)
Weight (pounds)
-------------------------------------------------61 ........................................... 236
62 ........................................... 242